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Being vigilant and aware of the signs of domestic abuse can help safeguard patients and staff alike

Daniel Pelka was four years old when he died of a head injury in March 2012, following months of abuse and neglect during which he was subjected to horrific acts of cruelty. His mother and stepfather were convicted of his murder in August 2013, and shortly afterwards the serious case review (SCR) into the circumstances of Daniel’s death reported its findings.1

A specific issue highlighted in the SCR was that Daniel’s mother had relationships with three different partners, all of which involved domestic violence and a high consumption of alcohol. There were 27 reported incidents of domestic abuse at the family’s home, but this vital information was not adequately shared between the relevant agencies in contact with Daniel and his family. “The child protection risks…in this volatile household were not fully perceived or identified” and opportunities for intervention were missed.1

Primary care professionals are among those front line staff whose work may bring them into contact with people living in abusive relationships. But although domestic abuse within a family is a risk to both children and vulnerable adults, healthcare staff do not always have the confidence and competence to address this issue.

Identifying and preventing domestic violence and abuse presents a challenge for clinical and non-clinical staff alike, given its scale as a public health issue:

- On average, two women are killed every week, and one man is killed every two and a half weeks, by their current or former partner.

- In 2012, around 1.2 million women suffered domestic abuse, more than 400,000 women were sexually assaulted, and 60,000 women were raped.

- Nearly a third of women and a fifth of men say they have experienced domestic abuse since the age of 16.

- Women are assaulted on average 35 times before they seek help.2

The extent of the problem is likely to be far greater than these figures suggest because not only is there a very low reporting rate from victims, but the government’s definition of domestic abuse has recently been extended to encompass non-violent abuse (Box 1).3 It is not uncommon for victims to live in abusive situations for many months or even years.

Domestic abuse is not confined to any one section of society, and men as well as women can be victims. Those at greatest risk are:

- Women who are separated from their partners.
Mothers on their own with children.

- Women on low incomes (less than £10,000 per annum).

- Women with chronic illnesses or disabilities that limit their independence.4,5

Many of these women will have frequent contact with health professionals especially in general practice; appropriate intervention from primary care could therefore prove pivotal. Research has shown that where victims disclose in response to sensitive questioning they express relief that someone has asked for and listened to their story. While midwives routinely ask women about domestic abuse antenatally at their booking appointment, other health professionals find broaching the subject less easy. Yet domestic abuse is linked not only to physical injuries – some of which may be life-threatening or seriously disabling – but also to other conditions that are less obvious. Chronic long-term pain or illness may be a marker for domestic abuse, as may mental health conditions such as depression, anxiety, post-traumatic stress disorder, paranoia and obsessive-compulsive symptoms. Abuse of alcohol and drugs may be both a factor in, and a result of, domestic abuse. Clinical and non-clinical staff, as well as patients, need to be involved in raising awareness in your practice. It is also important to recognise that employees may have personal experience of domestic abuse (Box 2). You can help to inform staff and patients by:

- Providing clear and accessible information as well as helpline numbers, relevant details of local facilities, including interpreting services, and contacts within the practice (see Resources).

- Showing awareness of different types of abuse including those specific to certain cultures, such as female genital mutilation and forced marriage.

- Involving staff in formulating a policy relating to domestic abuse that explains clearly what this is and how to respond to a disclosure, whether by a victim or a perpetrator.

A practice policy will need to include:

- The new extended definition of domestic abuse (Box 1).

- Domestic abuse care pathways for clinical staff to follow.

- The practice medical lead, as well as other key personnel specialising in domestic abuse.

- Local resources that can be offered to victims if domestic abuse is suspected or disclosed, including emergency accommodation and helpline numbers.

- Cross references to the practice safeguarding policies in relation to children as well as vulnerable adults.

Currently there is no requirement for practitioners in primary care, other than midwives, to ask about domestic abuse routinely, but it is essential to highlight its importance and ensure that training enables staff to:

- Recognise risk factors that may be indicative of abuse.

- Raise the subject sensitively.

- Respond appropriately to disclosure from victims or perpetrators.

- Follow guidance about documenting any disclosure of domestic abuse.

- Refer patients to specialists in domestic abuse.

- Ensure that psychological and practical support can be accessed where appropriate.

- Share information with other agencies, wherever possible with the consent of the patient involved.

- Be mindful of those occasions where confidentiality must be breached to safeguard others including children or vulnerable adults in a household.

Training for non-clinical staff should not be overlooked. They may have a very important part in helping to detect or prevent ongoing abuse; for example, by raising concerns in relation to:

- Any visible physical marks seen on adults or children (see case study).

- Abusive behaviour witnessed in a waiting area.

- Unusual behaviour in relation to contacts with the practice; for example, frequent requests for appointments and/or last minute cancellations.

- Inappropriate questioning by a patient’s partner about appointments or medical conditions.

The damage caused by domestic abuse harms not only adult victims. Children in abusive households are at significant risk: they may be killed or sustain life-threatening injuries. Where they remain exposed to domestic abuse their physical, emotional and social development may be seriously impaired. As adults they are at greater risk of perpetuating the cycle of domestic abuse in their future relationships.

Encouraging early recognition of domestic abuse within your practice could prove crucial in arresting the suffering and potential harm that would otherwise be caused to adult and child victims.

Responding to domestic abuse: Guidance for general practices. Produced by the Royal College of General Practitioners, Coordinated Action Against Domestic Abuse (CAADA) and Identification & Referral to Improve Safety (IRIS).